Sexually transmitted infections and child sexual abuse — branching viva

Stem

The examiner will test whether you can interpret an STI as graded forensic evidence and run a trauma-informed, safety-first evaluation of suspected child sexual abuse. [1]

Branch 1 — The positive result

Examiner: A four-year-old's vaginal swab is positive for gonorrhoea. How do you grade this finding? [1]

Strong answer: Gonococcal infection at a non-conjunctival site in a prepubertal child beyond the neonatal period is a strong marker of sexual contact. The result is graded forensic evidence, not a routine infection. I exclude perinatal acquisition, but perinatal gonorrhoea rarely persists to this age — unlike chlamydia, which can persist for two to three years and changes the interpretation materially. [1] [6]

Examiner: What if the same organism were chlamydia in an 18-month-old? [6]

Strong answer: I would weigh perinatal acquisition much more heavily, because chlamydia acquired at birth can persist into the second and third year of life. The history and the maternal record would shape interpretation, and I would still ensure the child is safe while I clarify the picture. [6]

Branch 2 — The evaluation

Examiner: Walk me through your history and examination. [2]

Strong answer: Safety first. I take a trauma-informed, child-led history without interrogation, because the detailed forensic interview belongs to trained child-protection interviewers. I capture perinatal, maternal, immunisation and bleeding-disorder context, and for post-menarchal adolescents, menstrual and pregnancy status. I examine in a trained setting with consent and a chaperone, using a colposcope and photo-documentation, and I record findings against normal variants. A normal or non-specific exam is found in most substantiated cases and never excludes abuse. [2] [1]

Branch 3 — Acute assault and the forensic window

Examiner: A 14-year-old discloses rape eight hours ago. What changes? [7]

Strong answer: This is now an urgent forensic and safety response. I confirm she is safe, address acute distress and suicidality, and preserve evidence — advise against washing, bathing or changing clothes, and retain clothing. I collect forensic samples within the evidence window, because forensic yield concentrates in the early hours after assault, although DNA may recover beyond 24 hours in selected cases. I maintain chain of custody and do not discharge her into danger. [7] [4]

Branch 4 — Prophylaxis

Examiner: Her contact's HIV status is unknown. What do you offer? [5]

Strong answer: I assess HIV post-exposure prophylaxis against source status, exposure type and time since contact. At eight hours she is well within the window where PEP is considered, and the unknown source status pushes toward offering it per local protocol. I add STI prophylaxis per the CDC STI Treatment Guidelines sexual-assault regimen, update hepatitis B vaccination, and offer emergency contraception because she is post-menarchal. I confirm exact regimens and windows from local protocol. [5] [3]

Branch 5 — Confidentiality, reporting and follow-up

Examiner: How do you frame confidentiality and the reporting duty? [2]

Strong answer: I state conditional confidentiality: what she says stays private unless there is a serious risk of harm, abuse or exploitation, or a legal duty to act. I make the child-protection notification my jurisdiction requires, and I never promise absolute secrecy that the reporting duty would then break. I plan any override with her as far as possible. [2]

Examiner: What is your follow-up plan? [8]

Strong answer: I schedule window-period re-testing and serology at the intervals local protocol sets, and I arrange trauma-informed psychological follow-up, because the long-term mental-health associations of childhood sexual abuse are well established. I name a concrete next contact so she is not lost between services. [8]

Examiner extras

• The infection is treatable; the interpretation is forensic. [1]
• A normal examination never overrides a credible disclosure or a strong-marker STI. [2]
• The forensic window is short — collect early, and do not defer for administrative reasons. [7]
• Perinatal chlamydia can persist for years; perinatal gonorrhoea rarely does. [6]